What is the recommended approach to evaluate and treat a patient presenting with vertigo, including how to differentiate peripheral from central causes and the appropriate management steps?

Vertigo Evaluation and Management Pathway

Initial Clinical Categorization by Timing and Triggers

Begin by classifying vertigo into one of four distinct syndromes based on timing and triggers rather than descriptive terms, as this framework directly guides diagnosis and management. 1

The Four Vestibular Syndromes

• Acute Vestibular Syndrome: Continuous dizziness lasting days to weeks with nausea, vomiting, and intolerance to head motion—includes vestibular neuritis, labyrinthitis, and posterior circulation stroke 1

• Triggered Episodic Vestibular Syndrome: Brief episodes (<1 minute) triggered by specific head/body position changes—includes BPPV (most common at 42% of cases) and postural hypotension 1

• Spontaneous Episodic Vestibular Syndrome: Episodes lasting minutes to hours without triggers—includes vestibular migraine, Ménière's disease, and vertebrobasilar TIA 1

• Chronic Vestibular Syndrome: Dizziness lasting weeks to months—includes anxiety disorders, medication side effects, and posterior fossa masses 1

Differentiating Peripheral from Central Causes

Critical Nystagmus Characteristics

Peripheral vertigo nystagmus:

• Horizontal with rotatory component, unidirectional, suppressed by visual fixation, fatigable with repeated testing, and has 5-20 second latency before onset 1

Central vertigo nystagmus:

• Pure vertical (upbeating or downbeating) without torsional component, direction-changing without head position changes, not suppressed by visual fixation, and does not fatigue 1
• Baseline nystagmus present without provocative maneuvers is a red flag for central pathology 1

Associated Symptoms Indicating Central Pathology

• Central vertigo frequently presents with dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, or Horner's syndrome 1
• Severe postural instability with falling is characteristic of central causes, particularly vertebrobasilar insufficiency and cerebellar lesions 1

Duration Patterns

• Vertebrobasilar insufficiency (central): Episodes typically last <30 minutes without hearing loss 1, 2
• BPPV (peripheral): Episodes last <1 minute 1
• Ménière's disease (peripheral): Sustained attacks lasting hours with fluctuating hearing loss, aural fullness, and tinnitus 1
• Vestibular neuritis (peripheral): Continuous vertigo lasting days to weeks 1

Immediate Physical Examination: The Dix-Hallpike Maneuver

Perform the Dix-Hallpike maneuver bilaterally on all patients presenting with vertigo to diagnose or exclude BPPV. 1

Peripheral (BPPV) Findings:

• Torsional and upbeating nystagmus with 5-20 second latency 1
• Crescendo-decrescendo pattern 1
• Fatigues with repeat testing 1
• Resolves within 60 seconds 1

Central Pathology Findings:

• Immediate onset without latency 1
• Persistent nystagmus that does not fatigue 1
• Purely vertical (downbeating or upbeating) without torsional component 1
• Downbeating nystagmus on Dix-Hallpike without torsional component mandates urgent MRI 1

Red Flags Requiring Immediate Neuroimaging

Any of the following demand immediate MRI brain with diffusion-weighted imaging: 1

• Severe postural instability with falling 1
• New-onset severe headache with vertigo 1
• Any additional neurological symptoms (dysarthria, diplopia, limb weakness, sensory deficits) 1
• Downbeating nystagmus on Dix-Hallpike without torsional component 1
• Purely vertical nystagmus without torsional component 1
• Baseline nystagmus present without provocative maneuvers 1
• Failure to respond to appropriate peripheral vertigo treatments 1
• Limb weakness or hemiparesis 1
• Truncal/gait ataxia 1

Critical pitfall: Approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders, and 25% of patients with acute vestibular syndrome have cerebrovascular disease (rising to 75% in high vascular risk cohorts) 1

Management by Diagnosis

BPPV (Confirmed by Positive Dix-Hallpike)

Perform canalith repositioning procedure (Epley maneuver) immediately upon diagnosis—do not delay treatment. 1

• Success rate: 80% after 1-3 treatments, 90-98% with additional maneuvers if initial treatment fails 1
• Do not prescribe vestibular suppressants for BPPV—they prevent central compensation 1
• Do not impose postprocedural postural restrictions 1
• No imaging is necessary for typical BPPV with characteristic nystagmus on Dix-Hallpike 1
• Reassess within 1 month; if symptoms persist, repeat Dix-Hallpike and perform additional repositioning maneuvers 1

Vestibular Neuritis/Labyrinthitis

• Initial stabilizing measures with vestibular suppressant medication 3
• Follow with vestibular rehabilitation exercises 3
• Vestibular electrical stimulation may reduce antigravity failure 4

Ménière's Disease

Key distinguishing features:

• Classic triad: episodic vertigo lasting hours, fluctuating sensorineural hearing loss that worsens over time, tinnitus, and aural fullness 1
• Fluctuating hearing loss is the critical feature distinguishing Ménière's from vestibular migraine 1

Treatment:

• Dietary sodium restriction 1
• Diuretics 1
• Vestibular rehabilitation 1
• Transtympanic corticosteroid or gentamicin injections for refractory cases 5

Vestibular Migraine

Diagnostic criteria:

• Vertigo episodes with migraine symptoms (headache, photophobia, phonophobia, visual aura) during at least 50% of episodes 1
• Stable or absent hearing loss (not fluctuating like Ménière's) 1
• Lifetime prevalence 3.2%, accounts for up to 14% of vertigo cases 1
• Episodes can be short (<15 minutes) or prolonged (>24 hours) 1

Treatment:

• Dietary modifications and lifestyle interventions 1
• Tricyclic antidepressant 3
• Beta blocker or calcium channel blocker 3

Vertebrobasilar Insufficiency

Clinical features:

• Episodes lasting <30 minutes without hearing loss 1
• Severe postural instability 1
• Gaze-evoked nystagmus 1
• Nystagmus does not fatigue and is not suppressed by gaze fixation 1
• May precede stroke by weeks or months—requires urgent vascular imaging 1

When NOT to Order Testing

• Do not obtain neuroimaging in patients meeting BPPV diagnostic criteria without red flags 1
• Do not order routine CT head for isolated dizziness—diagnostic yield is <1% (MRI is 4%) 1
• Do not order vestibular testing in patients meeting diagnostic criteria for BPPV without additional vestibular signs/symptoms inconsistent with BPPV 1

Exceptions Requiring Additional Testing:

• Atypical clinical presentation 1
• Equivocal or unusual nystagmus findings on Dix-Hallpike 1
• Additional symptoms suggesting CNS or otologic disorder 1
• Multiple concurrent peripheral vestibular disorders suspected 1

Medication-Induced Vertigo

Review all medications, particularly:

• Aminoglycosides (gentamicin)—can cause irreversible vestibular toxicity 1
• Anticonvulsants (carbamazepine, phenytoin, Mysoline) 1
• Antihypertensives 1
• Cardiovascular medications 1

Common Pitfalls to Avoid

• Overlooking vestibular migraine—it is under-recognized despite being extremely common in patients with both migraine and vertigo 1
• Failing to distinguish fluctuating hearing loss (Ménière's) from stable/absent hearing loss (vestibular migraine) 1
• Missing cerebellar stroke—10% present similar to peripheral vestibular disorders 1, 2
• Overlooking subtle neurological signs that indicate central pathology 1
• Prescribing vestibular suppressants for BPPV—they prevent central compensation 1
• Failing to recognize multiple concurrent peripheral vestibular disorders (e.g., BPPV with Ménière's disease or vestibular neuritis) 1

Imaging Recommendations by Presentation

CT Temporal Bone

• First-line for conductive hearing loss without middle ear mass 6
• Identifies otosclerosis, ossicular erosion, superior semicircular canal dehiscence 6
• Not indicated for routine vertigo evaluation 6

MRI Brain with Diffusion-Weighted Imaging

• Mandatory for any red flag features 1
• Required when clinical categorization between peripheral and central is difficult 6
• Essential to exclude posterior fossa tumors, vestibular schwannomas, and perilymphatic fistula 1